ACORD 25, Certificate of Liability Insurance Completed Form Examples and Samples

Hi Tom,

Please issue a new Certificate of Liability Insurance for our client, Apex Construction Inc. Their address is 123 Industrial Way, Suite 400, Boulder, CO 80301. The certificate needs to be dated for today, October 26, 2025. Please use cert number CERT-2025-987, revision 0.

The certificate holder is Urbanscape Properties LLC, located at 45 Park Avenue, Denver, CO 80202. They must be listed as an Additional Insured on the General Liability and Umbrella policies. Also, a Waiver of Subrogation is required for GL, Auto, and WC, as per their contract for the 'Parkside Tower construction project'. Please add this project name to the description.

Here are the policy details you'll need:

Commercial General Liability is with Granite State Assurance (NAIC #11111). It's an occurrence policy, #GCP-987654321, effective 06/01/2025 to 06/01/2026. Limits are $1M per occurrence, $2M general aggregate, $2M products/completed operations aggregate, $100k for damage to rented premises, $5k for med ex, and $1M for personal injury. The general aggregate applies per project.

Their Auto policy is with Patriot National Indemnity (NAIC #22222), policy #BAP-12345ABC, covering any auto with a $1M combined single limit. Same policy period.

The Workers' Comp is through Summit Workers Comp Co. (NAIC #33333), policy #WC-8889900. Limits are statutory, but Employers' Liability is $1M/$1M/$1M. All officers are included, so mark 'N' for the exclusion question. The dates match the others.

Finally, they have an Umbrella policy with Aegis Excess & Surplus (NAIC #44444). It's an occurrence policy, #UMB-5556677, with limits of $5M each occurrence and $5M aggregate. Policy dates are also June 1, 2025, to June 1, 2026.

I'll be the authorized representative on this. All our producer contact info for Keystone Insurance Group (555 Insurance Plaza, Denver, CO 80203) should be standard. My direct line is 303-555-0101 ext 25, fax is 303-555-0102, and email is [email protected]. Let me know once it's sent.

Thanks,
Sarah Jenkins

Subject: Updated COI Request - GreenScape Solutions - Project #8829

Hi Sarah, I hope your week is going well. I’ve finalized the certificate for your upcoming commercial landscaping contract at the Oakwood Corporate Park. We have listed Liberty Mutual Insurance (NAIC 23035) as our primary carrier for the General Liability policy (Policy #GL-998231), which is effective from 01/15/2026 to 01/15/2027. We are maintaining a $2,000,000 General Aggregate and $1,000,000 Each Occurrence limit. 

Regarding the fleet, we have Hartford Insurance (NAIC 29459) covering the trucks under policy #AUTO-55421. The coverage is set for 'Any Auto' with a $1,000,000 combined single limit. We have also included an Umbrella policy with AIG (NAIC 19402) policy #UMB-7721, effective 01/15/2026, providing an additional $5,000,000 limit. 

For Workers Comp, we are using Travelers (NAIC 25658), policy #WC-1102, which is also valid through January of next year. Please note that no officers are excluded from this policy. Our office, Apex Insurance Group, located at 4400 Business Park Way, Suite 100, Columbus, OH 43215, has authorized this document. You can reach our lead agent, Marcus Thorne, at 614-555-0199 or via fax at 614-555-0188. Send the certificate to the facility manager at Oakwood Management, 1200 Oakwood Drive, Columbus, OH 43220. Let me know if you need any adjustments to the operations description, currently listed as 'Routine grounds maintenance and landscaping services for commercial property'.